ni hms 147092

Psychosocial Stress during Pregnancy

Sarah M. Woods, BA1, Jennifer L. Melville, MD, MPH2,3, Yuqing Guo, MSN4, Ming-Yu Fan,PhD3, and Amelia Gavin, PhD, MSW51University of Washington School of Medicine, Seattle, Washington, USA2Department of Obstetrics and Gynecology, Seattle, Washington, USA3Department of Psychiatry & Behavioral Sciences, Seattle, Washington, USA4University of Washington School of Nursing, Seattle, Washington, USA5University of Washington School of Social Work, Seattle, Washington, USA

AbstractObjectiveTo identify factors associated with high antenatal psychosocial stress and describe thecourse of psychosocial stress during pregnancy.

Study DesignWe performed a cross-sectional analysis of data from an ongoing registry. Studyparticipants were 1,522 women receiving prenatal care at a university obstetrical clinic from January2004 through March 2008. Multiple logistic regression identified factors associated with high stressas measured by the Prenatal Psychosocial Profile stress scale.

ResultsThe majority of participant reported antenatal psychosocial stress (78% low-moderate,6% high). Depression [OR 9.6(5.517.0)], panic disorder [OR 6.8(2.916.2)], drug use [OR 3.8(1.212.5)], domestic violence [OR 3.3(1.48.3)], and having 2 medical comorbidities [OR 3.1(1.85.5)] were significantly associated with high psychosocial stress. For women who screened twiceduring pregnancy, mean stress scores declined during pregnancy [(14.83.9 versus 14.23.8;(p

1, has not routinely been measured in everyday obstetric practice. It has recently come to theforefront of policy, however, with The American College of Obstetricians & Gynecologists(ACOG) releasing a 2006 committee opinion stating that psychosocial stress may predict awomans attentiveness to personal health matters, her use of prenatal services, and the healthstatus of her offspring. 2 In this committee opinion, ACOG advocated screening all womenfor psychosocial stress and other psychosocial issues during each trimester of pregnancy andthe postpartum period. 2

Despite these recommendations the prevalence of antenatal psychosocial stress is unclear 3and its influence on maternal health is likely underestimated. Further, little research existsregarding which factors contribute to or coexist with psychosocial stress during pregnancy. Inthe few studies conducted to date, associations have been noted between antenatal psychosocialstress and domestic violence 48, substance use 9, 10, depressive symptoms 1113, psychiatricdiagnoses 14, poor weight gain 10, and having a chronic medical disorder. 10 Many of thesestudies were limited, however, in their sample size, select populations, or assessment ofpotential covariates (e.g. use of non-validated measures or medical records only). Some ofthese identified factors are known to be associated with adverse birth outcomes (e.g. pretermdelivery 1517, low birth weight 1618), so determining their associations with psychosocialstress is paramount.

Research regarding the factors associated with high psychosocial stress during pregnancy haspotential to provide targets for interventions, leading to an increase in maternal well-being anda potential decrease in adverse birth outcomes. The primary aims of this study were to identifyfactors associated with high antenatal psychosocial stress and describe the course ofpsychosocial stress during pregnancy.

Materials and MethodsDesign/Sample/Setting/Timeframe

We studied pregnant women enrolled in a longitudinal study of antenatal care at a singleuniversity obstetrical clinic. The clinic serves a group of women with diversity in race, socio-economic status (SES), and medical risk, with a payer mix of 46.5% private insurance, 51.6%Medicaid, and 1.9% self-pay. 19 Clinic providers include attending physicians, fellows,residents, and midwives. As part of a psychosocial screening program, questionnairesmeasuring stress and mood were introduced in January 2004. Questionnaires were designedto be distributed by clinical staff as part of routine clinical care to all women at least onceduring pregnancy with the goal of 2 times; first during the early 2nd trimester and again in the3rd trimester. All women receiving ongoing obstetrical care and completing at least onequestionnaire from January 2004 through March 2008 were eligible for inclusion in the study.Exclusion criteria included age less than 15 years at the time of delivery and inability tocomplete the clinical questionnaire due to mental incapacitation or language difficulties (i.e.,no interpreter available). Clinical staff were asked to contact and consent potentially eligiblesubjects at the time of screen completion. All procedures were approved by the University ofWashingtons Institutional Review Board.

MeasuresData were collected from self-report questionnaires and from automated medical records. Thequestionnaire included inquiry regarding demographic characteristics, social history,medication use, general health history, past obstetrical complications, as well as validatedmeasures assessing psychosocial stress 20, 21, depression and panic disorder 14, 22, tobacco use23, alcohol use 24, drug use 25, and domestic violence. 26 Maternal age and parity were obtainedfrom the automated medical record.

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Psychosocial stress was measured using the Prenatal Psychosocial Profile stress scale, whichhas been validated for use in pregnant populations. 20, 21 It is an 11 question survey using aLikert response scale with possible scores ranging between 11 and 44 (see Appendix). Thescales validity and reliability have been supported among ethnically diverse rural and urbanpregnant women. 20 Several recent studies have used this instrument to measure psychosocialstress. 4, 5, 8, 9, 11, 2729 In these studies, mean stress scores ranged from 17 to 23. 4, 5, 9, 11,21, 29 The recommended cut-off for high stress depends upon the population studied and thepatient characteristics; there are no recommendations for differentiating low to moderate stress.In the two studies that have established cut-offs for high stress, one used scores above the meanplus 2 standard deviations (score >26) 5 while another chose a set percentile of 25% (score 23) 28. Both of theses studies had predominantly low SES participants. In our heterogeneousSES population, we chose a cut-off of scores above the mean plus 2 standard deviations corresponding to a score of 23 for our sample.Depression and panic disorder were assessed using the Patient Health Questionnaire (PHQ)short form (15-items), which yields diagnoses for major depression, minor depression, andpanic disorder. In a study of 3,000 OB/GYN patients, high sensitivity (73%) and specificity(98%) for the depression items were demonstrated for a diagnosis of major depression basedon the Structured Clinical Interview for DSM-IV (SCID). 14, 22 This was also true fordiagnostic items related to panic disorder (sensitivity 81%, specificity 99%). 22 In our study,women meeting DSM-IV criteria for major or minor depression on the PHQ-9 were classifiedas experiencing current depression. The criteria for major depression require the subject tohave, for at least two weeks, five or more depressive symptoms present for more than half thedays, with at least one of these symptoms being depressed mood or anhedonia. 14 The criteriafor minor depression require the subject to have, for at least two weeks, two to four depressivesymptoms present for more than half the days, with at least one of these symptoms beingdepressed mood or anhedonia. 14 Women were classified as having current panic disorder ifthey answered yes to five diagnostic criteria for panic disorder.

Tobacco, alcohol, and drug use were assessed using the Smoke-Free Families Prenatal Screen23, the Alcohol T-ACE 24, and the Drug CAGE 25. The Smoke-Free Families Prenatal Screenwas specifically developed to maximize disclosure of smoking status during pregnancy andany current smoking is classified as tobacco use. 23 Both the T-ACE and the Drug CAGE assesssubstance use during the current pregnancy as well as in the 12 months prior to pregnancy toidentify all women at risk for use. The T-ACE was developed to identify at risk drinkers, hasbeen validated in a pregnant population, and has increased sensitivity compared to the AlcoholCAGE. 24 Sensitivity and specificity of identifying at risk drinkers are 69% and 89% when ascore of 2 on the T-ACE is used. 24 The Drug CAGE, developed from the original CAGE toidentify problem illicit drug use, has been validated in pregnant women with a cut-off score of 3 identifying problem drug use. 25 In this study, women were considered as at risk drinkersor problem drug users if they met criteria for risk drinking or problem drug use duringpregnancy and/or in the 12 months prior to pregnancy.

The 3-question Abuse Assessment Screen 26 assesses physical and sexual violence during thepast year and during pregnancy. This screen has been used both as a clinical screening toolwith established validity and test-retest reliability, and for research purposes as a dichotomousmeasure of abuse. 4, 5, 8, 18, 30 Consistent with previous research studies, we classified womenas positive for domestic violence if they answered yes to any of the three abuse questions.

Women were considered as having high medical comorbidity if they self reported 2 chronicmedical problems outside of pregnancy (e.g., asthma, hypertension, diabetes, or cardiovascularproblems). A history of pregnancy complications was recorded for patients who self reportedone or more significant pregnancy complications (e.g., gestational diabetes, pre-eclampsia,

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eclampsia, preterm delivery, or placental abruption) in a prior pregnancy. Other demographicsincluding employment, education, and marital status were dichotomized as shown in Table 1.

AnalysisUnivariate analysis was performed for the sample characteristics by stress level (high stressversus other, 2 test for categorical variables and T-test for continuous variables, significanceat p < 0.05). Significant variables from the univariate analysis and variables established apriori were entered into a multiple logistic regression model to determine associations withhigh psychosocial stress. Variables were added to the model one by one and were excludedfrom the final model if they did not improve the overall model fit. For women who completedscreening at two time points, their mean stress scores were compared using a paired T-test.

Questionnaire data for each subject was entered and stored using Filemaker Pro (FilemakerProVersion 9 for Windows 19942008, Santa Clara, California: FileMaker, Inc). Data wasanalyzed using SPSS (SPSS for Windows, Rel. 15.0.1. 2001. Chicago: SPSS Inc.).

ResultsDuring the study period 2,046 women completed at least one psychosocial screen as part oftheir routine antenatal care. All women completing a screen were eligible for the study. Staffwere present in clinic to contact around 80% (n=1,639). Of 1,639 women whom staff wereable to contact for involvement in the study, 92.9% (n=1,522) consented for participation while7.1% (n=117) declined.

Among the 1,522 study participants, mean age was 30.4 6.3 years, with a range of 1551years. Racial identification was 66.9% White, 10.9% Asian, 7.6% Black, 2.2% AmericanIndian or Alaska Native, 1.2% Pacific Islander, 5.5% mixed race, and 5.7% undeclared.Ethnicity was nine percent Hispanic. The index pregnancy was the first pregnancy for 53.7%(n=818). The majority of women reported living with a spouse or partner (87.3%, n=1,234)and had achieved education beyond high school (79.2%, n=1,118). Twelve percent (n=169)reported that they were unemployed. All other maternal demographic, behavioral, and clinicalcharacteristics are reported in Table 1.

Six percent (n=91) of women reported high stress, 78% (n=1,190) reported low/moderatestress, and 16% (n=241) reported no stress. The mean gestational age at first screening was23.5 7.3 weeks and mean stress score was 15.0 4.0. Forty-three percent (n=658) of theenrolled women completed screening at two time points during pregnancy. For this subset,mean gestational age at 1st screening was 22.1 6.0 weeks with mean stress score of 14.8 3.9; and mean gestational age at 2nd screening was 36.3 1.8 weeks with mean stress score14.2 3.8. A statistically significant difference in mean stress scores from 1st to 2nd screeningwas found (P < 0.001).

Adjusted odds ratios from the logistic regression examining the relationship between maternalcharacteristics and high psychosocial stress are shown in Table 2. Five maternal characteristicswere significantly associated with high psychosocial stress. Domestic violence, drug use, andhaving two or more medical problems increased the odds of high psychosocial stress duringpregnancy by 3 to 4 fold, while current depression and panic disorder increased the odds by 7to 10 fold. Conversely, marital status, employment, education, race, age, and history ofpregnancy complication were not significantly associated with high psychosocial stress in thefinal model.

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CommentIn a population of ethnically and economically diverse pregnant women attending a university-based prenatal clinic, antenatal psychosocial stress was common, with slightly higher meanlevels earlier in pregnancy. High levels of antenatal psychosocial stress were significantlyassociated with depression, panic disorder, drug use, domestic violence, and having two ormore medical comorbidities. Our study adds significantly to a small body of literature regardingfactors associated with antenatal stress.414 It firmly establishes an independent associationbetween current psychiatric mood disorders (major/minor depression, panic disorder) and highantenatal psychosocial stress. It improves upon prior studies showing a relationship betweendepressive symptoms or psychiatric disorders and increased stress during pregnancy 1114, byusing diagnostic criteria and assessing for multiple potential confounders. For substance use,we found psychosocial stress to be associated with risky drug use, but not alcohol use. Twoprevious studies have linked substance use with high psychosocial stress 9, 10, but these studieswere limited in that one combined alcohol and drug use in a single variable and the other usedmedical records to determine substance use during pregnancy. Our results are distinctive inthat we measured alcohol use and drug use individually with separate, validated measures. Thestrong independent association between domestic violence and antenatal stress found in ourstudy strengthens the conclusion of prior studies. 48 We further found that chronic medicalproblems are independently associated with high antenatal psychosocial stress. Our findingsdid not show a significant independent association between antenatal psychosocial stress andseveral maternal characteristics seen in prior studies ( i.e., race 7, 31, 32, marital status 31, age7, education 7, poverty 7, 32, and cigarette smoking 3335).

Levels of psychosocial stress likely change throughout the course of pregnancy, although fewstudies have measured psychosocial stress at different antenatal time points. 3, 21, 3638 Ourstudy found a significant decrease in mean stress scores from first to second screening,consistent with the findings of several prior studies. 20, 21, 36, 37 Although statisticallysignificant, the decrease in the actual score was small and whether this is clinically significantmerits further investigation. In contrast to this observed decline in antenatal stress shown inours and other studies, higher rates of low birthweight and preterm delivery have been notedin studies where levels of antenatal stress rose during pregnancy. 3, 36, 37 Thus, not only thelevel of stress but the time point in pregnancy during which high maternal stress is experiencedmay be influential in regard to risk of adverse outcomes.

Our study has a number of strengths, including utilization of a routine screening protocol withhigh level of subject participation, large sample size, use of accurate measurement of multiplecovariates, and adjustment for biomedical, demographic, psychosocial, and behavioral factorsin our models. Among prior studies, our study is unique in accurately assessing a large numberof potential confounders to establish a more complete model for antenatal psychosocial stress.We are limited, however, by the use of cross-sectional data, allowing assessment of associationsbut not causality or temporal sequence between specific factors and high psychosocial stress.In addition, only a subset of the sample completed two screens during pregnancy, limiting theamount of information obtained regarding the change in stress during pregnancy. Lastly, themajority of the data were self-reported, which may lead to underreporting of sensitivebehaviors.

Depression 17, panic disorder 17, domestic violence 15, 18, drug use 16, and having medicalcomorbidities 39, 40 are all known to be individually associated with poor obstetrical outcomes.Antenatal psychosocial stress contributes to maternal distress and may also be associated withadverse pregnancy outcomes (e.g. LBW 3, 10, 4144, PTD 3, 28, 37, 41, 45, 46). Therelationship of the above maternal factors with psychosocial stress and the way in which theylead to adverse outcomes is unknown, but may occur via indirect behavioral and direct

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physiologic pathways. 47, 48 Behavioral responses to stress may include alterations in nutrition,sleep, exercise, substance use, tobacco use, and/or use of prenatal services. 10, 47 Whilephysiological responses to psychosocial stress may include both neuroendocrine and immuneresponses. 47, 49

Identification of pregnant women experiencing significant psychosocial stress presents healthcare providers an opportunity to further assess the nature of the stress and alerts them to assessfor associated risk factors. Decreasing high antenatal psychosocial stress in itself will improvematernal well-being. Although many of the factors associated with stress are difficult toovercome (e.g., poverty, racism, lifetime exposure to violence) 27, success may be found inspecific health behavior interventions designed to reduce stress (e.g., nutritional counseling,physical and mental relaxation, education, and social support). 50 Poor health behaviors andstress often coexist and predate pregnancy, so it can be argued that interventions should beintroduced across a womans reproductive lifespan (preconception, perinatal, and internatal).47, 50, 51 Decreasing high stress and/or addressing associated risk factors may also decreasethe risk of adverse pregnancy outcomes. The screening protocol applied in this study is a modelfor screening in a prenatal clinic 19, identifying not only women experiencing stress, but alsothose with depression, panic disorder, substance use, and domestic violence. Withidentification of these other factors, health care providers are provided additional specific focifor intervention.

In conclusion, antenatal psychosocial stress during pregnancy is common, and high stress isassociated with multiple maternal factors that are known to contribute to poor pregnancyoutcomes. Our findings lend support to recent ACOG recommendations to screen forpsychosocial stress during pregnancy. 2 Future investigations are planned to further investigaterelationships between antenatal psychosocial stress and pregnancy outcomes.

AcknowledgmentsFunding from:

1. 1 TL1 RR025016-01, UW Multidisciplinary Predoctoral Research Training Program (National Center for ResearchResources (NCRR), a component of the National Institutes of Health (NIH) and NIH Roadmap for Medical Research)

2. 1 KL2 RR025015-01, NCRR, NIH Roadmap for Medical Research

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APPENDIX.

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Tabl

e 1

Mat

erna

l Dem

ogra

phic

, Beh

avio

ral,

and

Clin

ical

Cha

ract

eris

tics b

y Ps

ycho

soci

al S

tress

Cat

egor

y

Cha

ract

eris

ticT

otal

(n=1

,522

)H

igh

Stre

ssT

est

Stat

istic

(t or

2)

p-va

lue

Yes

(n=9

1)N

o(n

=1,4

21)

Age

(yea

rs)

30.4

(6.

3)28

.0 (

6.6)

30.6

(6.

3)3.

676

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Cha

ract

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otal

(n=1

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igh

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est

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istic

(t or

2)

p-va

lue

Yes

(n=9

1)N

o(n

=1,4

21)

Eth

nici

ty2.

302

0.31

6

H

ispa

nic

9.0%

(n=1

37)

8.8%

(n=8

)9.

1% (n

=129

)

N

on-H

ispa

nic

81.1

% (n

=1,2

34)

76.9

% (n

=70)

81.5

%(n

=1,1

58)

U

ndec

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d9.

9% (n

=151

)14

.3%

(n=1

3)9.

4% (n

=134

)

Pari

ty0.

756

0.38

5

Pr

imip

arou

s53

.7%

(n=8

18)

58.2

% (n

=53)

53.6

% (n

=761

)

M

ultip

arou

s46

.3%

(n=7

04)

41.8

% (n

=38)

46.4

% (n

=660

)

Cur

rent

Cig

aret

te S

mok

ing

75.8

08

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Cha

ract

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(n=1

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igh

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est

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istic

(t or

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Yes

(n=9

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o(n

=1,4

21)

Pani

c D

isor

der

101.

189

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NIH



Table 2

Adjusted Odds of High Psychosocial Stress during Pregnancy

Maternal Characteristic Adjusted Odds Ratio 95% Confidence Interval

Current depression1 9.6 (5.5, 17.0)

Panic disorder 6.8 (2.9, 16.2)

Drug use 3.8 (1.2. 12.5)

Chronic health problems (2) 3.1 (1.8, 5.5)Domestic violence 3.3 (1.4, 8.3)

Not married/partnered 1.6 (0.8, 3.2)

Unemployed 1.7 (0.9, 3.3)

High school 1.1 (0.6, 2.2)Race

White 1.0 Reference

Black 1.3 (0.5, 3.1)

Asian 1.1 (0.4, 2.9)

Other2 1.1 (0.6, 2.3)

History of pregnancy complications 1.2 (0.7, 2.1)

Maternal age 1.0 (1.0, 1.0)

1Major or minor depression

2Other category includes American Indian, Pacific Islander, Mixed, Undeclared


ni hms 147092

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